The nurse is providing care for a client diagnosed with post-thrombotic syndrome who has a venous stasis ulcer. Which instructions should be given prior to discharge? (Select all that apply)
Increase intake of proteins, take vitamin C and zinc
Use care when walking to avoid bumping your limb
Cleanse the ulcer with soap and water
Apply cortisone cream to decrease itching
Put on compression stockings before getting out of bed
Correct Answer : A,B,E
Choice A rationale
Proteins, vitamin C, and zinc are essential for wound healing. Proteins are the building blocks for body tissue, and zinc plays a role in protein synthesis. Vitamin C is needed for the formation of collagen, a protein used to make skin, scar tissue, and blood vessels.
Choice B rationale
Care should be taken when walking to avoid bumping the limb. Any trauma to the affected limb could potentially worsen the condition or delay healing.
Choice C rationale
Cleaning the ulcer with soap and water may not be the best option. Soap can be irritating to the skin and may delay healing. Instead, the ulcer should be cleaned as per healthcare provider’s instructions.
Choice D rationale
Cortisone cream is not typically used for venous stasis ulcers. It can thin the skin and delay healing.
Choice E rationale
Compression stockings are often recommended for patients with post-thrombotic syndrome. They can help reduce swelling and improve blood flow, which can promote healing of the venous stasis ulcer.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Placing the patient back on the heparin infusion and redrawing laboratory values would not be the appropriate next step. The INR of 1.9 is below the therapeutic range of 2.0 - 3.0 for most patients on warfarin. Therefore, the warfarin therapy is not yet fully effective, and there is no need to revert to heparin.
Choice B rationale
Asking the healthcare provider if the patient’s medication can be changed to rivaroxaban would not be the appropriate next step. Rivaroxaban is a different type of anticoagulant and would not necessarily be more effective in this situation.
Choice C rationale
Notifying the healthcare provider and asking if the dose of warfarin can be increased would be the appropriate next step. The INR of 1.9 is below the therapeutic range of 2.0 - 3.0 for most patients on warfarin. Therefore, an increase in the warfarin dose may be necessary to achieve therapeutic anticoagulation.
Choice D rationale
Preparing to administer a dose of Vitamin K subcutaneously would not be the appropriate next step. Vitamin K is used to reverse the effects of warfarin and would be counterproductive in this situation.
Correct Answer is C
Explanation
Choice A rationale
Omitted meals can lead to hypoglycemia, not diabetic ketoacidosis (DKA). DKA is caused by a lack of insulin, not a lack of food intake.
Choice B rationale
Polydipsia and polyphagia are symptoms of hyperglycemia, not causes of DKA. They occur as the body tries to compensate for high blood sugar levels.
Choice C rationale
Not taking enough insulin is a primary cause of the development of DKA. Without enough insulin, the body begins to break down fat for fuel, which produces acids known as ketones.
Choice D rationale
An insulin overdose would lead to hypoglycemia, not DKA. DKA is caused by a lack of insulin, not an excess.
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